SAMPLE POLICY
To be used as a guideline only
SUICIDE PRECAUTIONS
Policy
It is the policy of _____________ Hospital to implement interventions by the staff for patients
with suicidal ideation.
Purpose
To delineate procedures to be undertaken when a suicide precaution order has been written or
when suicidal precautions must be initiated.
PROCEDURES AND GUIDELINES:
SUPPORTIVE DATA:
1. Patients at high risk for suicide include the depressed, the patient with alcohol and
drug problems, and some schizophrenics who are experiencing bizarre delusions and
hallucinations (especially command hallucinations). Suicide risk increases in patients
who have made prior attempts, those with a family history of suicide, and those who
are isolated (e.g., no support system, recent loss, lonely). Common modes of suicide
include hanging (most common id a hospital setting), jumping, suffocation, overdose
(cheeking and contraband), and by slashing or puncture wounds.
CONTENT STATEMENT:
ASSESSMENT AND IMPLEMENTATIONS:
1. All patients, at the time of admission, will be assessed for potential suicide risk by the
admitting nurse.
2. Based on the results of the Admission Suicide Assessment outcome, patients will be
placed on Level I (Low Risk), Level II (Moderate Risk), or Level III (High Risk);
and, a physician’s order will be obtained.
3. In cases in which the patient has verbalized and/or demonstrated suicidal thoughts not
previously recognized, an assessment is immediately completed by the Registered
Nurse; the patient is placed on a higher level of suicide precautions; and the physician
is notified following implementation.
4. The patient should be assigned a room in close proximity to the nurses’ station,
whenever possible.
5. Patients will be informed of any restrictions/safety measure to be implemented.
6. A clothing and property search (pockets, jackets, shoes, socks, and bags) for
contraband (weapons, etc.) and/or denied articles (glass, sharps, matches, etc.) will be
conducted. Removed items are placed in a secured area.
7. Whenever a patient makes a death-related statement, the following will occur:
a. the patient is immediately upgraded to a higher level of suicide precautions;
b. the statement is documented in the medical record in quotations;
c. the physician is notified following implementation.
8. Staff will be assigned to monitor the patient as follows:
LEVEL I (LOWEST)
1. Observation every 30 minutes and verbal contact at least every 60 minutes during
waking hours, and documented on the patient observation checklist.
2. Therapeutic activities are limited to the unit unless accompanied by psychiatric
nursing staff. Patients are allowed to leave the unit when accompanied by psychiatric
nursing staff.
3. Denied articles may be left out for personal use but must be returned immediately
after use.
4. Patients will be monitored at least every 30 minutes.
LEVEL II (MODERATE RISK)
1. Observation every 15 minutes and verbal contact at least hourly during waking hours
and documented on the patient observation checklist.
2. Activities, including meals, are limited to the unit.
3. Denied articles must be used in the presence of staff. Belts, shoelaces, and all
drawstrings are removed.
4. Patients will be monitored at least every 15 minutes throughout the night.
LEVEL III (HIGH RISK)
1. Observation will be continuously one-to-one (direct line of sight, including
throughout the night) and documented on the patient observation checklist
2. Verbal contact with the patient at least every 30 minutes during waking hours.
3. Body searches will be conducted by two staff members (of the same sex), if ordered
by the physician.
4. All belts, shoelaces, and drawstrings are removed.
5. The patient will be restricted to the unit, including meals (paper service/plastic
silverware).
6. Use of denied articles will be limited and under supervision.
ANY EXCEPTION TO THE ABOVE CRITERIA MUST BE BY SPECIFIC
PHYSICIAN’S ORDER.
REASSESSMENT/DISCHARGE
1. The patient is to be reassessed by the RN every shift, using the Ongoing Suicide
Assessment form and monitored according to the determined level. Physicians will be
notified of any change.
2. Physician’s orders to be renewed every 24 hours.
3. The RN will reassess any patient assessed as having been at risk during his/her
hospitalization prior to dismissal note.
Page 2 of 3
SAFETY CONCERNS:
1. Staff will inspect the unit each shift for Safety of Environment
2. Patients are to be monitored at irregular times.
3. Patients will be monitored when taking medications. Medication may be given
crushed or in a liquid form, if necessary.
4. Level II and III patients will not be allowed off the unit unless specifically ordered by
the physician.
5. Packages brought by visitors will be checked in at the nurses’ station. Staff must be
present when packages are opened.
6. Patients on all levels are restricted from passes.
7. Body searches may be conducted when indicated, with a physician’s order.
REPORTABLE CONCERNS AND EMERGENCY MANAGEMENT:
Suicide precautions are not to be discontinued until 24 hours have indicated that the
patient is no longer at risk (a scoring below Level I rating). A physician’s order to
discontinue is to be obtained.
DOCUMENTATION:
1. The Close Observation Checklist will be used to document the monitoring of the
patient. On completion, the checklist is placed in the patient’s record.
2. A Progress Note is to be entered by staff on each shift regarding the current status and
behavior of the patient.
3. A Progress Note by an RN is required at least daily. The entry must reflect the current
assessment status as it relates to the patient’s potential risk for suicide.
Page 3 of 3
SUICIDE PRECAUTIONS
LEVEL I - MILD
30 MINUTE OBSERVATION
SYMPTOMS:
1. Evidence of suicidal ideation of intent is
present but patient states no intent of
action. Patient is without a plan.
INTERVENTIONS:
1. Precaution checks every 30 minutes in
Nurses Notes.
2. Indirect verbal or behavioral messages
from patient indicates possible suicide risk.
2. Frequent verbal contact while awake,
minimum every hour.
3. Patient is willing to make a “No Suicide”
contract.
3. A “No Suicide” contract is written and reassessed every 24 hours.
4. Patient is not longer assessed a Level II
suicide risk by both physician and staff.
4. Patient’s whereabouts are known by staff at
all times.
5. Patient presents insight into existing
problems.
5. Patient may go off unit only one to one
with staff member.
SUICIDE PRECAUTIONS
LEVEL II - MODERATE
15 MINUTE OBSERVATION
SYMPTOMS:
1. Evidence of serious suicide attempt(s),
patient has a plan
INTERVENTIONS:
1. Precaution checks recorded every 15
minutes on Close Observation Form.
2. Patient communicates verbally or
behaviorally a serious plan of suicide.
2. Frequent verbal contact while awake,
minimum every 30 minutes.
3. Patient brought to the hospital because of
active suicide attempt in recent past and is
still considered at risk.
3. Whereabouts of patient known by staff at
all times.
4. Patient is ambivalent about making a
contract.
4. Immediate restriction to unit. Monitor use
of bathroom and shower providing
assistance and direction as needed.
5. Limit amount of patient belongings to a
safe minimum.
5. Patient has minimal insight into existing
problems, has limited impulse control.
6. Patient is no longer assessed a LEVEL III
suicide risk by physician and staff.
6. Visitors may be restricted at the discretion
of the physician or staff (a physician’s
order will be obtained if it is necessary to
restrict visitors).
SUICIDE PRECATUIONS
LEVEL III - HIGH
CONSTANT OBSERVATION
SYMPTOMS:
1. Patient is currently verbalizing a clear
intent to harm self.
INTERVENTIONS:
1. One-to-one staff observation of patient 24
hours a day. Precaution checks recorded
every 15 minutes on the Close Observation
Form.
2. Patient is responding to hallucinations
and/or delusions that make a suicide
attempt imperative.
2. Frequent verbal contact with patient while
awake.
3. Patient is unwilling to make a contract.
3. Immediate restriction to room; visitors
restricted (a physician’s order will be
obtained to restrict visitors). All belts,
shoelaces, drawstrings, and pantyhose
denied.
4. Patient has no insight into existing
problems.
4. Limit amount of patient belongings to a
safe minimum.
5. Patient has poor impulse control.
5. Monitor use of bathroom and shower,
providing assistance and direction as
needed.
6. Patient has attempted suicide in the recent
past by a particular lethal method (e.g.,
hanging, guns, self-mutilation, carbon
monoxide).
6. Observations, assessment, and interaction
documented in Nurses Notes by licensed
personnel each shift.
ADMISSION SUICIDE ASSESSMENT GUIDELINES
I.
PURPOSE
To assess the patient’s suicide potential at the time of admission
II.
General Instructions:
A. The Admission Suicide Assessment is completed at the time of admission.
B. A Registered Nurse completes the assessment.
C. The form is completed in black ink and placed in the front of the chart.
D. The form is a permanent part of the patient record.
III.
SPECIFIC INSTRUCTIONS:
A. Check any item that applies to the assessed patient.
B. Add the total score and divide the total by four.
C. Circle the assessed level at the bottom of the form.
D. Sign, date, and time the assessment.
E. Addressograph on the lower right hand corner of the form.
F. The physician is notified of the patient’s assessed suicide level.
G. The patient is placed on patient observation and the patient observation form is
activated for assessed levels of I-IIII.
ADMISSION SUICIDE ASSESSMENT
Check the most applicable criterion and add the score. Divide by 4 to determine the assessed
level. Circle the assessed level, date, time, and sign the assessment.
A.
NATURE OF PRECIPTIATING EVENT
_____ 3 pts. Loss of Love Object (person, i.e.: mother, father, child, significant other)
_____ 2 pts. Major Catastrophic Life Change (loss of job, divorce, separation, major illness,
major accident, financial catastrophe, professional status, social status)
_____ 1 pt. Minor Catastrophic Life Change (loss of property, extended family member,
friend, idol)
_____ 0 pts. No apparent precipitating factor
B.
TIME SINCE PRECIPITATING EVENT
(if not specific event, since onset of acute depressive symptoms)
_____
_____
_____
_____
3 pts.
2 pts.
1 pt.
0 pts.
C.
INTENSITY OF SUICIDAL IDEATION
_____
_____
_____
_____
3 pts.
2 pts.
1 pt.
0 pts.
D.
LETHALITY OF ATTEMPT
(patient may lack sophistication in method)
One week or less
One to four weeks
Four weeks to one year
No apparent precipitating event
Acute, recent onset with or without precipitant
Chronic, long term with recent precipitant
Chronic, long term with no precipitant
No suicidal ideation
_____ 3 pts. Obvious Lethal Attempt within past 90days (use of lethal weapon or implement in
a lethal way, e.g., gun, hanging, drowning, overdose, car, knife)
_____ 2 pts. Apparent Non-Lethal Attempt (less lethal means or relatively lethal with
intervention likely)
_____ 1 pt. Obvious Non-Lethal Attempt
_____ 0 pts. No suicide attempt
LEVEL I
.75-2.0
LEVEL II
2.10-2.9
LEVEL III
3.0
Date ________________
Time ______________
RN Signature __________________
ONGOING SUICIDE ASSESSMENT GUIDELINES
I.
PURPOSE
The Ongoing suicide Assessment Form is used to assess the patient suicide potential
while on suicide precautions.
II.
GENERAL INSTRUCTIONS
A. The Ongoing Suicide Assessment is completed by the Registered Nurse for each shift
while the patient is on suicide precautions.
B. The form is completed in black ink and placed in front of the chart.
C. The form is a permanent part of the patient’s record.
III.
SPECIFIC INSTRUCTIONS
A. Check any item that applies to the assessed patient in each level.
B. A check in any level higher than Level I warrants placement of the patient into that
higher level.
C. Circle the highest level that includes a checkmark.
D. Notify the physician of any level increases to obtain an order.
E. Use the patient observation form for observation documentation.
F. The Registered Nurse signs, dates, and times the assessment.
G. Addressograph the lower right hand corner of the form.
ONGOING SUICIDE ASSESSMENT
LEVEL I (Any of the following)
_____ Patient verbalized suicidal thoughts or feeling with no plan
_____ Sudden change in behavior, e.g., has been hopeless and is suddenly cheerful
LEVEL II (Any one of the following)
_____ Patient verbalizes suicidal ideation with a plan and means to carry it out
_____ High level of hopelessness, helplessness, guilt, or anxiety.
_____ Patient is unwilling to make a contract with staff
_____ Attempt at self-harm is presenting problem upon admission
LEVEL III (Any one of the following)
_____ Suicide attempt while hospitalized
_____ Conceals equipment that could be used to harm self
_____ Repeated attempts to self-mutilate
_____ Command hallucinations to kill self
INSTRUCTIONS





Circle the assessed level
Notify physician of any increase in level to obtain order
For Level III, make arrangements to transfer patient to locked unit, if applicable
for Levels II and III, all belts, shoelaces, and drawstrings are removed
Use patient observation checklist for documentation.
LEVEL I
LEVEL II
LEVEL III
RN Signature __________________________________________________________________
Date _________________________________
Time _______________________________
SUICIDE CONTRACT GUIDELINES
PURPOSE:
The purpose of the Suicide Contract is to extract from a suicidal patient a written promise to do
no harm to herself/himself while at the hospital. This contract also provides to the patient a
written promise that the staff will assist him/her in utilizing alternate methods of coping with the
suicidal ideation.
PROCEDURE:
If and when a patient has verbalized or displayed suicidal ideation/intent, a designated staff
member discusses the situation with the patient. The contract is read and explained to the patient.
The patient is asked to sign and the patient signature line and the staff member signs on the
witness line.
SUICIDE CONTRACT
I will not harm myself while I am a patient at _______________________ Hospital. If, at any
time, I feel I may harm myself I will ask a staff member to talk with me.
________________________________________
Witness
________________________________________
Patient Signature
________________________________________
Date